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Journal Article > Study
Collard HR, Saint S, Matthay MA. Ann Intern Med. 2003;138:494-501.
Health care–associated infections (HAIs) are a common adverse event in hospitalized patients and an increasing source of study for preventive strategies. Ventilator-associated pneumonia (VAP) is one of the four most common HAIs along with catheter-related bloodstream infection, catheter-associated urinary tract infection, and surgical site infection. This systematic review provides a series of recommendations to reduce the incidence of VAP, including use of semi-recumbent positioning, sucralfate rather than H2-antagonists, and aspiration of subglottic secretions in select patient populations. The authors point out that while many studies highlight the success of preventive strategies, no randomized trial has evaluated the effects of combining the preventive practices as an additive bundle or checklist.
ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.
This is an alert from the Institute for Safe Medication Practices informing readers of a fatal medication error that occurred because of a misinterpreted decimal point. The error involved administration of morphine to a 9-month-old infant who received 5 mg instead of 0.5 mg of the drug. The order did not include a zero before the decimal point, and the nurse filling the order overlooked the omission. The child suffered a cardiac arrest and died. The case illustrates the importance of clearly communicating information about medications.
Eichhorn JH, Cooper JB, Cullen DJ, Philip JH, Maier WR, Seeman RG. JAMA. 1986;256:1017-1020.
To proactively devise a patient safety strategy for anesthesia, the authors of this article summarized a series of mandatory standards implemented at Boston's nine component teaching hospitals. The authors discuss the detailed process that led to the highlighted standards, including the need to balance physician autonomy with the larger goal of improving patient care. One of the objectives from their efforts was to demonstrate the applicability of the process and to counter increases in anesthesia-related malpractice claims. They suggest the need for both a strong commitment to leadership and the development of a process to foster similar standards and improvements throughout the country.
Wu HW, Nishimi RY, Page-Lopez CM, Kizer KW. Washington, DC: National Quality Forum; 2005.
In the 2003 report Safe Practices for Better Healthcare, the National Quality Forum (NQF) recommended 30 practices, one of which emphasized improved communication in the informed consent process. This report builds on that safe practice endorsement by summarizing strategies for rapid and widespread adoption. The report describes experiences from four hospitals that successfully implemented the practice and discusses common barriers and solutions involved. Recommendations are provided to guide health care organizations still striving to meet the requirement for an effective informed consent process.
Journal Article > Commentary
Howanitz PJ. Arch Pathol Lab Med. 2005;129:1252-1261.
This study utilized the College of American Pathologists' (CAP) database to outline a series of performance measures targeted at improving patient safety. Investigators examined summarized data from ongoing studies of the CAP database and evaluated the error rates and prevention strategies implemented to develop recommendations. The author discusses eight performance measures, including customer satisfaction, test turnaround times, patient identification, and critical value reporting, while generating benchmarks and practical guidance for integrating the measures into every laboratory. Conclusions call for wide application of such performance improvement activities, both to establish best practices and to ensure standards for patient safety in the laboratory setting.
Journal Article > Study
Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.
To grade progress since release of the landmark Institute of Medicine (IOM) report, this AHRQ-funded study examined the status and evolution of patient safety systems through a survey of acute care hospitals in Missouri and Utah. Investigators characterized their assessment based on variables that included presence of computerized physician order entry systems, computerized test results, evaluation of adverse drug events, specific patient safety policies, use of data in patient safety programs, drug administration and safety procedures, error reporting processes, prevention policies, and root cause analyses. More than 100 hospitals completed the survey in 2002 and again in 2004. Findings demonstrated only modest improvements in certain areas with variability noted in others. For instance, surgical areas and medication processes seemed to embrace the greatest level of patient safety systems. However, the authors point out that the overall findings fall short of the IOM recommendations and necessitate a more intensive agenda for accelerated improvements. An accompanying editorial (link below) provides an overview of the factors and challenges involved in promoting change to improve patient safety.
A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
Journal Article > Study
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
This AHRQ-supported study analyzed information from nearly 3 million operations between 1985 and 2004, discovering a rate of 1 in 112,994 cases of wrong-site surgery. Investigators further evaluated cases with available medical records, all of which were among the malpractice claims. In doing so, they noted that the Joint Commission's Universal Protocol might have prevented only 62% of the cases reviewed. At the rates reported, the authors suggest that the average large hospital may be involved in such an event every 5 to 10 years, a rate 10 times less frequent than retained foreign bodies. They also point out that while wrong-site surgery is a devastating and unacceptable outcome, current efforts to implement protocols may not prevent every event and may, in turn, create inefficiency in related processes. The authors offer a series of recommendations for a model site-verification protocol. The American College of Surgeons offers a fact sheet on correct-site surgery geared toward patient education.
Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.
Health care–associated infections (HAIs) remain the most common adverse event affecting patients while hospitalized and after discharge. However, applying patient safety techniques as well as traditional infection control methods has resulted in significant successes in curbing these infections. This practice guideline, developed by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, summarizes preventive interventions and implementation strategies for prevention of the four most common HAIs (catheter-related bloodstream infection, ventilator-associated pneumonia, catheter-associated urinary tract infection, and surgical site infection). Evidence-based recommendations are also provided for limiting the transmission of methicillin-resistant Staphylococcus aureus and preventing Clostridium difficile infections.
Journal Article > Commentary
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.
Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.
Michaels AD, Spinler SA, Leeper B, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Quality of Care and Outcomes Research, Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Cardiovascular Nursing, Stroke Council. Circulation. 2010;121:1664-1682.
Patients hospitalized with acute coronary syndromes or strokes are particularly vulnerable to medication errors, as many of these patients are elderly, have complex medication regimens, or are administered high-risk medications such as anticoagulants. This position paper from the American Heart Association reviews the specific types of medication errors in these patients, including dosing errors, administration of contraindicated medications, and errors of omission (failure to prescribe recommended therapies). The authors make specific, evidence-based recommendations for preventing medication errors in this patient population, including integrating pharmacists into inpatient teams and using computerized provider order entry and medication reconciliation to detect and prevent errors. A medication error in an acute coronary syndrome patient is illustrated in this AHRQ WebM&M commentary.
Journal Article > Study
Huskins WC, Huckabee CM, O'Grady NP, et al; STAR*ICU Trial Investigators. N Engl J Med. 2011;364:1407-1418.
Antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecalis (VRE), are frequent sources of hospital-acquired infection (HAI) in the intensive care unit (ICU). Although the incidence of serious infections caused by MRSA has been decreasing, the optimal strategies to prevent spread of these bacteria remain unclear. In this cluster-randomized trial conducted in 18 ICUs, a protocol that involved universal surveillance and barrier precautions (gowns and gloves) for patients colonized with these bacteria was evaluated for effectiveness at preventing colonization and infection with MRSA or VRE. No reduction in colonization or infection was found, in part attributable to the fact that use of barrier precautions was suboptimal. Prior successful efforts to reduce HAI have emphasized the role of safety culture in addition to specific preventive interventions, an approach discussed in-depth in this analysis of the landmark Keystone ICU project.
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.
Shekelle PG, Wachter RM, Pronovost PJ, eds. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 13-E001-EF.
The seminal AHRQ Making Health Care Safer report, issued in 2001, used evidence-based medicine principles to identify key patient safety practices (PSPs). Although its recommendations were somewhat controversial, the report galvanized patient safety efforts at hospitals nationwide and provided a stimulus for further rigorous research on PSPs. In doing so, the report laid the foundation for the most prominent successes of the safety field. This newly issued follow-up report combines traditional systematic review methodology with the judgments of key stakeholders and technical experts in the field. The authors critically examine the evidence supporting 41 separate PSPs and ultimately arrive at a list of 10 strongly encouraged practices. These practices, if implemented, should result in reduced harm from a wide range of safety threats, including health care–associated infections, medication errors, and pressure ulcers. The report also examines how cost, implementation, and contextual considerations may affect the real-world effectiveness of PSPs, details how foundational concepts such as human factors engineering should be incorporated into safety efforts, and provides a blueprint for future research in patient safety. Formal systematic reviews of 10 key PSPs are also being published simultaneously in a special supplement to the Annals of Internal Medicine.
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
Wrong-site surgery is a never event, but still occurs at alarming rates. This report discusses risks related to wrong-site surgery, along with their root causes, and describes initiatives associated with a Joint Commission Center for Transforming Healthcare project. The authors highlight improvements in scheduling surgeries, preoperative processes, operating room preparations, and organizational culture that substantially reduced wrong-site surgeries in the eight hospitals participating in the program. A prior AHRQ WebM&M commentary by Dr. Charles Vincent discussed a case of a wrong-site procedure.
Journal Article > Study
Barker AL, Morello RT, Wolfe R, et al. BMJ. 2016;352:h6781.
Falls in hospitalized patients are a common source of preventable harm, and the incident is considered a never event when it results in serious injury. Conducted at six Australian hospitals, this cluster randomized controlled trial sought to evaluate the effectiveness of a bundled intervention on the incidence of falls on adult wards. The bundle included assessing patients' risk for falling along with several widely used tactics to prevent falls. Despite successful implementation of the fall prevention bundle, falls occurred just as frequently on intervention wards as control wards. This study is an important example of the need to rigorously evaluate safety interventions, even those that have high face validity. The authors conclude that since these interventions appear ineffective. Organizations should consider disinvestment in these practices because completing ineffective interventions consumes a significant amount of staff time and effort. A WebM&M commentary discussed a case involving a fall resulting in injury.